analysis of the primary presenting symptoms and

1

Analysis of the primary presenting symptoms and

hematological findings of COVID-19 patients in Bangladesh

Abu Taiub Mohammed Mohiuddin Chowdhury1, Md Rezaul Karim2, H.M. Hamidullah Mehedi3,

Mohammad Shahbaz4, Md Wazed Chowdhury5, Guo Dan1, Shuixiang He1*

1Dept. of Gastroenterology, First affiliated hospital of Xi’an Jiaotong University, Xi’an, China. 1Hubei Key Laboratory of Embryonic Stem Cell Research, Institute of Neuroscience, Hubei

University of Medicine, Shiyan, China. 3Chattagram General Hospital, Chattagram, Bangladesh. 4Chakaria Upazilla Health Complex, Cox’s Bazar, Bangladesh. 5Civil Surgeon’s Office, Chattagram, Bangladesh.

*Correspondence to: Prof. Dr. Shuixiang He, Dept. of Gastroenterology, First affiliated hospital

of Xi’an Jiaotong University, Xi’an, Shaanxi 710061, China. Email: [email protected];

And, Dr. Abu Taiub Mohammed Mohiuddin Chowdhury, Dept. of Gastroenterology, First

affiliated hospital of Xi’an Jiaotong University, Xi’an, Shaanxi 710061, China. Email:

[email protected]

ABSTRACT: Objective: SARS-Cov-2 infection or COVID-19 is a global pandemic. From the

time of identification to till, multiple clinical symptoms and parameters have been identified by

the researchers of various countries and regions regarding the diagnosis and presentations of

COVID-19 disease. In this manuscript, we investigated the primary symptoms and basic

hematological presentations of SARS-CoV-2 infection among the Bangladeshi patients.

Methodology: We have collected the disease history of mild to moderate degree of COVID-19

patients; hematological and biochemical on admission reports of moderate degree COVID-19

patients. All of them were tested positive for SARS-CoV-2 by RT-PCR in different institutes in

Bangladesh. Results: According to this study though COVID-19 patients in Bangladesh

commonly presented with fever, cough, fatigue, shortness of breath, and sore throat, but

symptoms like myalgia, diarrhea, skin rash, headache, Abdominal pain/cramp, nausea, vomiting,

restlessness, and a higher temperature of >1000F have a greater presentation rate and more

Preprints (www.preprints.org) | NOT PEER-REVIEWED | Posted: 21 June 2020 doi:10.20944/preprints202006.0275.v1

© 2020 by the author(s). Distributed under a Creative Commons CC BY license.

https://doi.org/10.20944/preprints202006.0275.v1

http://creativecommons.org/licenses/by/4.0/

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frequent than other published studies. CRP and Prothrombin time was found to increase in all the

patients. Serum ferritin, ESR, SGPT, and D-Dimer were found increased among 53.85%, 80.43,

44%, and 25% patients respectively. 17.39% of the patients had leucocytosis and neutrophilia.

28.26% of patients presented with lymphocytopenia. 62.52% of patients had mild

erythrocytopenia. Conclusion: Despite some similarities, our study has evaluated a different

expression in presenting symptoms in the case of COVID-19 patients in Bangladesh. CRP,

Prothrombin time, serum ferritin, ESR, SGPT, D-Dimer, erythrocytopenia, and lymphocytopenia

can be initial diagnostic hematological findings and assessment for prognosis COVID-19 disease.

Also, gender variations have a different scenario of clinical and laboratory appearance in this

region.

Keywords: SARS-CoV-2; COVID-19; real-time RT-PCR; COVID-19 symptoms; COVID-19

hematological findings; Bangladesh

Introduction

SARS-Cov-2 infection or COVID-19 is a current global pandemic. This is a single-stranded

RNA virus originated from the beta Coronavirus family. [1] The rapid spread of SARS-CoV-2

has led to the declaration of a global pandemic barely three months after emerging [2]. The

disease was first notified in December 2019 in the Hubei province of the Republic of China as a

cluster of 27 cases of pneumonia of an unknown cause. [3] All these patients presented with

Radiological findings like glassy lung opacity along with clinical presentations like fever,

dyspnoea, and dry cough. From the time of identification to till, multiple clinical symptoms and

parameters have been identified by the researchers of various countries and regions regarding the

diagnosis and presentations of COVID-19 disease. In this manuscript, we investigated the

primary symptoms and hematological presentations of SARS-CoV-2 infection among

Bangladeshi patients.

Methodology

For the analysis of the presenting symptoms of SARS-CoV-2 infection, we collected the data of

COVID-19 patients from Chattagram Civil Surgeon’s office, and the Chakoria Upazilla Health

and Family Welfare Officer’s (UH&FPO) office. All the patients were tested positive for SARS-



3

CoV-2 by RT-PCR at Bangladesh Institute of Tropical and Infectious Disease (BITID) and

Cox’s Bazar Medical College Hospital and were treated (either as outpatient or as inpatient with

mild to moderate degree of illness) under different COVID-19 dedicated hospitals in Chattagram

district, and Chokoria Upazilla Health complex. A total of 638 patient’s data that were tested

positive from May 5th to June 5th, 2020 were collected. Each of the patients was individually

interviewed to find out the details of the disease symptoms, history, comorbid condition, and

associated complaints.

Patients with severe comorbid conditions like severe Bronchial asthma, COPD exacerbation,

severe ischemic heart disease, severe uncontrolled diabetes mellitus, advanced renal and hepatic

disease, patients with carcinoma, hospitalized and Immuno-compromised patients were not

included in this study. Due to misconception and unreliable statement 127patient's data were

discarded. 138 patients had comorbid conditions that affected the presenting symptoms or had

existing symptoms from before, so these were also excluded. 53 patients did not respond to our

call or unwilling to participate in the study. Following exclusion for symptomatic analysis 320

patients of 13 to 56 years (mean age 35.81 years) of age were included in this study.

To evaluate the hematological changes in the patients we gathered the hematological and

biochemical on admission reports of 89 admitted patients (moderate degree COVID-19 disease)

from May 5th to June 5th, 2020. This included Hemoglobin level, Erythrocyte Sedimentation rate,

total and differential count of WBC, RBC, Platelet, C-Reactive Protein (CRP), SGPT, Serum

Ferritin, Prothrombin time, D-Dimer, and Serum creatinine. According to the clinical

presentation patients with fever were tested for Dengue NS1 antigen, Dengue IgG & IgM

antibody, Salmonella Typhi IgM and IgG antibody, ICT for malaria (Antigen for Plasmodium

Falciparum, Vivax, Malaria, and Ovale) and Widal test to exclude Dengue, Malaria, and Enteric

fever. Patients who had a chronic comorbid condition and any recent history of hematological,

biochemical abnormalities, or chest radiograph abnormality within a period of 30days were not

included in this study. In our observation, all patients with severe diseases had pre-existing

comorbid conditions. Therefore, only the laboratory findings of patients with moderate COVID-

19 disease were collected. Following exclusion criteria (others as described earlier) 39 patients

were excluded from the study. A total of 50 patient’s data were included for the analysis. Male

37 male and 13 female of 31 to 59 years of age (mean 42.8 years).



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Informed consent was obtained in every case. Statistical analysis was done by Graphpad Prism

software.

Results and findings

Table 1: A total of 320 patients were included in the study. The patient’s ages were 13 to 56years.

208 (65%) were male and 112 (35%) were female. [Figure 1 A] The Mean age of the patients

was 35.81±11.68 years. The mean age of male and female patients was 34.16±11.08 years and

38.89±12.19 years respectively. [Figure 1 B] 129 (40.31%) patients were under hospital and 191

(59.69%) were under home isolation. Out of 320 patients, 262(81.88%) were symptomatic and

58 (18.13%) were asymptomatic. The age of male and female symptomatic patients was

34.15±11.07 years and 38.89 ± 12.19 years. The duration of symptoms was 5.66 ± 3.60 days in

general. In the case of male patients, this was 5.72 ± 3.50 days and female was 5.56 ± 4.0days.

[Figure 1 C]

Sub-group analysis of hospital/home isolated patients hospitalized patients 107 (82.3%) were

male, 23 (17.82%) were female; in the case of home isolation 141(71.57%) were male and 50

(26.18%) were female. [Figure 1 D] T-test was not significant among the groups. Age group was

as following 10 to 20 years 30patients, 21 to 30 years 53 patients, 31 to 40 years 127 patients, 41

to 50 years 71 patients, and 51 to 60 years 39 patients. [Figure 1 E]

Among all the patients, highest 220 (68.8%) patient presented with fever, weakness 134 (41.9%),

cough 126 (57.3%), anorexia 117 (36.6%), myalgia 112 (35.0%), diarrhea 98 (30.6%), nausea 94

(29.4%), chest tightness 93 (42.3%), sleep disturbance 83 (25.9%), headache 75 (23.4%), sore

throat 63 (19.7%), respiratory distress 61 (19.1%), rhinorrhoea 53 (16.6%), abdominal crump/

pain 53 (16.6%), small localize rash on the body (with or without itching) 47 (14.7%), vomiting

29 (9.1%), and vertigo 11 (3.4%). [Figure 2 A & B]

The maximum temperature was found 1040F. 220 patients had a history of fever and 100 patients

had no fever history. [Figure 2 D] Out of 220 patients presented with fever, 68 patients had

temperatures <1000F and 152 presented with >1000F temp. [Table 1] Febrile patients had a

history of a minimum of 2days and a maximum 14days with a mean of 6.09±3.69 days of fever

history. Patients with <1000F temperature had a history of 5.72 ± 5.13 days (2 to 14 days) and

patients with >1000F temperature had a history of 5.73±2.47 days (2 to 10 days) of febrile history.



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[Figure1 F] Among 126 patients with a history of cough 103 (81.75%) experienced dry cough

and 23 (18%) complained of sputum with cough; among them, males were 93(73%) and female

were 34 (26.95%). [Figure 2 E] Patients had 5.67±3.60 days (2-14 days) of history of symptoms

in general. Male patients have 5.72±3.5 days (2-13 days) and females had 5.56±4.0days (2-

14days) of the history of symptoms. These figures are not significant in the t-test, P=0.998.

Among the hospitalized patients 107 were male patients of 37±10.95years (22 to 54 years), 48

were female of 36.88±8.13 years (22 to 50years). In the case of home isolation, this was

34.16±10.93 years (17 to 54 years) in males and 39.82±9.84 (24 to 56years) in females. [Figure 2

F]

Table 2: Subgroup analysis of patients according to the symptoms. Fever was presented by

220patients, among this male were 157(71.36%) and females were 63(28.64%); this is 95.73%

and 64.29% against total symptomatic male and female patients. Weakness was presented by

134patients, male 98(73.13%), and female 36(26.87%); this is 59.76% and 36.73% against total

symptomatic male and female patients. The cough was presented by 126patients male 92(73.01%)

and female 34 (26.87%); this is 56.10% and 34.69% against total symptomatic male and female

patients. Anorexia was presented by 117patients, male 81(69.23%), and female 36(30.77%); this

is 49.39%% and 36.73% against total symptomatic male and female patients. Generalized

Myalgia was presented by 122 patients, male 87(77.68%), and female 25(22.32%); this is 53.05%

and 25.51% against total symptomatic male and female patients. Diarrhoea was presented by 94

patients, male 61(62.24%), and female 25(26.60%); this is 37.20% and 37.76% against total

symptomatic male and female patients. Nausea was presented by 98 patients, male 61(62.24%),

and female 37(37.76%); this is 42.07% and 25.51% against total symptomatic male and female

patients. Chest tightness was presented by 93 patients, male 52(55.91%), and female 41(44.08%);

this is 31.71% and 41.84% against total symptomatic male and female patients. Sleep

disturbance was presented by 83 patients, male 51(61.44%), and female 32 (38.55%); this is

31.10% and 32.65% against total symptomatic male and female patients. Headache was

presented by 75 patients, male 58(77.33%), and female 17(22.67%); this is 35.37% and 17.35%

against total symptomatic male and female patients. Sore throat was presented by 63 patients,

male 30(47.61%), and female 33 (52.38%); this is 18.29% and 33.67% against total symptomatic

male and female patients. Breathing difficulty was presented by 61 patients, male 43(70.49%),




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patients. Rhinorrhea was presented by 53 patients, male 30(56.60%), and female 23(43.31%);

this is 18.29% and 23.47% against total symptomatic male and female patients. Abdominal

cramp/pain was presented by 53 patients, male 27(50.94%), and female 28(52.83%); this is 16.46%

and 28.57% against total symptomatic male and female patients. Skin rash was presented by 47

patients, male 18(38.30%), and female 29(61.70%); this is 10.98% and 29.59% against total

symptomatic male and female patients. Vomiting was presented by 29 patients, male 22(75.86%),


patients. Vertigo was presented by 11patients, male 3(27.27%), and female 8(72.73%); this is

1.83% and 8.16% against total symptomatic male and female patients. Restlessness was

presented by 82patients, male 57(69.51%), and female 25(30.49%); this is 34.76% and 25.51%

against total symptomatic male and female patients. [Figure 3 A & B]

Table 3: 152 (47.50%) patients have a comorbid condition. 47 (30.92%) had T2 DM, 64 (42%)

had HTN, 23 (15.13%) had bronchial asthma, 17 (11.2%) had ischemic heart disease, 13 (8.55%)

has sinusitis, 20 (13.16%) had other manifestations like a fungal infection, hypothyroid, hepatitis

B (+)ve, etc. 42 (13.13%) had DM and HTN and 9 (2.81%) had DM-HTN-Ischemic Heart

Disease.

Table 4: Hematological findings, numbers of patients were n=50. Male 37 male and 13 female,

mean age was 42.8 ± 8.268 (31to 59years). Routine blood count was done on 46 patients,

findings with ranges were as following: Hemoglobin 13.42 ± 1.324 gm/dL (11.5 to 16.3 gm/dL);

ESR 29.52 ± 18.46 mm in 1st hour (4 to 46mm in 1st hour), WBC 6851 ± 2721 (4300 to

16000/CC), RBC 4.94 ± 0.65 Million/CC (3.75 to 5.94 Million/CC); Platelet 229804 ± 68932

/CC (160000- 421000/CC), Neutrophil 65.43 ± 12.11% (48 to 85%); Lymphocyte 28.72 ± 11.97 %

(20 to 45%), Monocyte 3.89 ± 2.42% (2 to 10%), Eosinophil 1.96 ± 1.26% (0 to 5%), Basophil

0.065 ± 0.24% (0 to 1%). CRP 16.65 ± 18.81 mg/dl (0.95 to 60.2 mg/dl, number of patients 43);

SGPT 72.04 ± 49.56 Unit/L (22 to 181, number of patients 25); Serum Ferritin 659.9 ± 488.9

ng/ml (169 to 1550, number of patients 26); Prothrombin Time 14.35 ± 0.95 seconds (13.6 to

15.7 seconds, number of patients 10); D-Dimer 0.25 ± 0.28 µgm/ml (0.025 – 0.68 µgm/ml,

number of patients 12), Serum Creatinine 1.08 ± 0.17 mg/dl (0.89 to 1.3 mg/dl, number of

patients 12).



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Subgroup analysis of the laboratory routine hematological findings based on patients gender

variations are as follows: Hemoglobin level was deceased among 71.42% male and 36.36%

female; ESR was increased in 80%male and 72.73% female; Leucocytosis was found in 17.14%

male and 18.2% female; Neutrophilic leucocytosis was detected in 17.14% male and 18.2%

female; Lymphocytopenia was found among 31.43% male and 18.18% female; Reduce RBC

level was noted in 27.27% female this was normal in all male patients. [Figure 3 D]

Subgroup analysis of patients biochemical evaluation depending on patients gender: CRP and

Prothrombin time (PT) was increased in all the male and female patients; increased SGPT level

was found among 52.94% male and 25% female; increased serum ferritin level was seen among

68.75% male and 37.5% female; 18.8% male and 100% of female (1 of 1 female patient) had an

increased level of serum D-Dimer. [Figure 3 F] Difference between the decrease hemoglobin

level (P=0.0243) and increased SGPT (P=0.0108) against male and female in Chi-square test and

t test patients were found significant, others are not. [Figure 3 G]

Discussion

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) causing COVID-19 has

rapidly evolved as an epidemic outbreak and infected more than six and a half million

individuals all over the world. Besides this, billions of others are directly affected by the citizens

are affected by measures of social distancing and the socio-economic impact. COVID-19 is a

systemic infection causing a significant impact on the hematopoietic system and hemostasis

mechanism. [3] The incubation period of this virus can be up to 14days following exposure.

According to the center for disease control and prevention (CDC), the individuals with COVID-

19 have had a wide range of symptoms reported ranging from mild to severe illness. These

symptoms may appear from the second day till the incubation period. These symptoms may

include but not limited to cough, fever, chills, muscle pain, the heaviness of chest, shortness of

breath or difficulty breathing, sore throat, and loss of taste or smell. Warning signs of COVID-19

include breathing difficulty, persistent pain or pressure in the chest, inability to wake or stay

awake, sings of central cyanoses like bluish lips or face, and confusion. [4] Multiple studies have

reported presenting symptoms of COVID-19 worldwide among which several symptoms are

common, but due to geographical locations, these symptoms may differ.



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In this study, we analyzed the COVID-19 cases in multiple centers in Bangladesh to

assess these symptomatic and hematological variations from the rest of the world. Following

exclusion, our study revealed that the primary presenting symptoms of 320 COVID-19 patients

in treated in multiple centers in Bangladesh include fever, cough, chest tightness, weakness,

anorexia, myalgia, diarrhea, nausea, sleep disturbance, headache, sore throat, respiratory distress,

rhinorrhea, abdominal pain, rash or skin lesion, vomiting, vertigo, and restlessness. Among these

primary presenting symptoms, fever and cough were most common, and vomiting and vertigo

were relatively uncommon. Chest tightness and weakness were relatively common in COVID-19

cases but not as much as fever and cough, which was present in the maximum number of cases

affected by SARS-CoV-2 [Figure 2 A & B]. This study can help healthcare professionals in

Bangladesh and others to narrow down the suspected COVID-19 affected cases and perform

testing accordingly. In Bangladesh, unlike developed countries, real-time reverse transcription-

polymerase chain reaction (RT-PCR) is the only available test which is recommended by the

Institute of Epidemiology, Disease Control and Research (IEDCR) for the healthcare settings.

The real-time RT-PCR is of the high value of interest for the detection of COVID-19 disease due

to its simplicity and specificity. [5-7] But unfortunately RT-PCR test has the risk of eliciting

false-negative and false-positive results, as the sensitivity and specificity of the RT-PCR test are

not 100%. [8] However, a chest computed tomography (CT) was reported 98% and 97%

sensitive in two different studies. [9, 10]

One of the early studies regarding clinical characteristics of COVID-19 done on 1099

patients in china revealed that the most common symptoms were fever, cough, and fatigue which

resembles findings of our study (68.8%, 57.3%, and 41.9%). [Figure 2 A & B] A study on the

systematic review focusing on upper airway symptoms revealed that the common symptoms of

COVID-19 were fever, cough, and fatigue. [11] These studies with our study confirm that fever

and cough are the two most common onset symptoms of COVID-19, including in Bangladesh.

Diarrhoea, on the other hand, was uncommon (3.8%) [12] Which is not uncommon in COVID-

19 cases analyzed in our study, 30.6%. Symptoms like Hemoptysis (0.9% Vs 0%) and breathing

difficulty (18.7% Vs 19.1%) show similarity with our findings. But Sore throat 13.9% Vs 19.7%;

Headache 13.6% Vs 23.4%; Nausea & Vomiting 5% Vs 29% & and 9.1%; Myalgia 14.9% Vs 35%

and Skin rash 0.2% Vs 14.7% has revealed a very different trends of presenting symptoms then



9

the other reported studies. Our findings of Diarrhoea (30.6%) are similar to Song et al. This

study reported SARS-CoV-2 induced diarrhoea could be the onset symptom in patients with

COVID-19. [13] Up to 30% of patients with the Middle East respiratory syndrome (MERS) and

10.6% of patients with SARS had diarrhoea as the onset symptom. [14] Bao et al. revealed that

vomiting is also associated as the onset symptom in some cases of COVID-19, [15] which was

also present in the COVID-19 cases found in our study (9.1%). A similar result was also found in

the case of rash/skin lesion in this study, which resembles a case study where a young male with

full-body rash was a presenting symptom of COVID-19. [16] 16.6% of the patients in our study

complained of mild to moderate amounts of abdominal cramp or pain. This finding also similar

to a case study reported earlier that the acute abdomen was the early symptom of COVID-19. [17]

During the data collection we have noticed 2 severe cases of COVID-19 with hemoptysis. As all

the severe cases had per existing comorbid conditions, so were not included in his study. We

have also observed three cases presented only with anorexia and two cases of severe myalgia

later were diagnosed as SARS-CoV-2 infection. As an additional finding, restlessness was

complained by 85 (25.63%) of patients this was 34.76% of symptomatic males and 25.51% of

the symptomatic females [Table 2]. Based on our study findings minimally symptomatic patients

or symptoms like abdominal cramp or pain, Myalgia, localize skin lesion or rash, sleep

disturbance, and restlessness are important presenting symptoms for this region of COVID-19

disease besides common other symptoms.

According to our study males have a higher infection rate than females 208 (65%) & 112 (35%).

[Figure 1 A] Also only 18.12% of patients were asymptomatic whereas symptomatic cases were

81.88%. [Figure 2 C] This is due to lack of test availability and also tests were made available

only to the definite symptomatic patients or those who have radiological or laboratory findings

suggestive of SARS-CoV-2 infection. The duration of symptoms had no variation depending on

gender and age. [Figure 1 C, Figure 2 F] Male patient’s home isolation and treatment number are

higher than the female patients. [Figure 1 D] In case of age group 31 to 40 years are the most

affected n= 127/320 and 10 to 20 are the least n=30/320. [Figure 1 E] Cases with or without

fevers were high 68.75% and 31.25% compare to Wei-jie Guan et al. [11] Duration of fever has

no significant difference regarding presenting temperature. [Figure 1 F] But temperature >1000F

was relatively higher then <1000F 47.5% and 21.25% of total patients, this is 152 (69.09%) and

68 (30.90%) [Table 1] of patients with fever and does not correlate with the other study. [11]



10

Male patients were more affected with cough than female and dry cough was more common than

sputum. [Figure 2 E] Fever, weakness, anorexia, Myalgia, nausea, headache, breathing difficulty,

vomiting, and restlessness were more prominent in the case of male than female patients. [Table

2, Figure 3 A & B] Chest tightness, sore throat, skin lesion/rash, and vertigo were more common

in female patients. [Table 2, Figure 3 A & B] Other than that diarrhea, sleep disturbance and

rhinorrhoea/nasal congestion have an almost similar presentation in both sexes.

SARS-CoV-2, on the other hand, is a systemic infection with a significant impact on the

hematopoietic system and hemostasis, according to the critical review by Terpos et al. done on

hematological findings of COVID-19. They have found that COVID-19 disease has prominent

manifestations from the hematopoietic system and is often associated with a major blood

hypercoagulability. The study indicated that Lymphopenia might be considered as a cardinal

finding with prognostic potential. On the other hand, Neutrophil/lymphocyte ratio and peak

platelet/lymphocyte ratio may also have prognostic value in determining severe cases.

Furthermore, blood hypercoagulability is common among hospitalized COVID-19 patients.

Elevated D-dimer levels are consistently reported as well. Thus, the study concluded that in

patients with COVID-19 either for hospitalized or not, are at high risk for venous

thromboembolism, and an early and prolonged pharmacological thromboprophylaxis with

LMWH is highly recommended. [18]

We had analyzed the on-admission laboratory values of 50 patients with moderate degree

of COVID-19 disease to assess the overall expression. The study revealed an increased level of

ESR, CRP, SGPT, S. Ferritin, Prothrombin time, and D-Dimer. However, the level of

Hemoglobin and RBC were decreased and also revealed leucocytosis, neutrophilia, and

lymphocytopenia. [Figure 2 C & D] The differential expression of WBC analysis revealed

normal mean Neutrophil, Lymphocyte, Monocyte and Eosinophil count. [Figure 3 F] Analysis of

biochemical values according to gender revealed differences between males and females in a few

parameters. Increased levels of SGPT and S. Ferritin were found among males, and increased

levels of D-Dimer were found among females (One in one patient). [Figure 3 E] There were no

differences in the levels of CRP and prothrombin times between males and females in patients

with COVID-19. [Figure 3 E] Hemoglobin count was decrease in case of male (71.42%) than

female (36.36%), though RBC count was normal in all the males and decreased among 27.27%

of female patients. [Figure 3 D] Difference between the decrease hemoglobin count and



11

increased SGPT against male and female patients were found significant. [Figure 3 G] All these

suggests us to provide more attention towards gender in cease of laboratory findings for COVID-

19 diagnosis and prognosis

One of our important observation was in delay in diagnosis and therefore treatment from the time

of appearance of symptoms, 5.67± 3.56 days. [Figure 1 C] This is probably explained by delay in

publishing test results (2 to 3days from sample collection) unwilling to take tests by patients due

to testing and social hazards, and strict indications followed for the PCR test (Fever, breathing

difficulty, chest discomfort, Chest X ray findings and associated hematological findings) by the

COVID-19 tertiary centre doctors due to limited resources.

Conclusion

According to this study COVID-19 patient in Bangladesh though has similarity with the

presenting symptoms like fever, cough and berating complaints, but symptoms like myalgia,

diarrhea, skin rash, headache, Abdominal pain/cramp, nausea, vomiting, restlessness, and a

higher temperature of >1000F have a greater presentation rate and more frequent even as an

isolated presentation of SARS-CoV-2 infection than other published studies. Hematological

findings like CRP and Prothrombin time were found to increase among all of our study patients.

Besides, an increase in Serum ferritin, ESR, SGPT, and D-Dimer along with erythrocytopenia

and lymphocytopenia can be important supportive diagnostic criteria. Due to differences in

presentations and difficulty in testing, some common symptoms create confusion regarding

diagnosis and mislead a SARS-CoV-2 infection like a common viral flue. This might cause

morbidity and mortality to COVID-19 patients. Moreover, a chest CT is neither affordable for

most of the patients nor available in rural healthcare settings in Bangladesh. So, there is a

possibility of patients affected by SARS-CoV-2 may remain undiagnosed due to a false negative

real-time RT-PCR test or not being sensitive to the real-time RT-PCR test. Thus, if further tests

can’t be done to confirm the diagnosis such as a chest CT in patients having these common

symptoms and hematological manifestations should be treated as COVID-19 patients to narrow

the spread of the COVID-19 and stop the symptomatic patients from developing severe illness

any further. Our study has limitations, namely the small sample size and selection of mild to

moderate cases that may affect the study outcome. But we believe the above findings will help to



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guide physicians and researchers to have a different view and better management of COVID-19

disease during this crisis period.

Conflict of Interests

None to declare.

Ethics Approval and Consent to Participate

The study was approved by the hospital ethics committee, First Affiliated Hospital of Xi’an

Jiaotong University, Xi’an, Shaanxi, China. The purpose of this research was explained to the

participant. Once the verbal consent was understood and agreed, a written consent was then

obtained from the participant. In the case of bellow 16 years old participants written consent was

obtained from a parent or guardian.

Authors’ contributions

ATMMC: concept development, data collection and analysis, statistical analysis, review and

manuscript writing; MRK: review and manuscript writing; MS and MWC: data collection;

HMHM: laboratory data collection; GD: data analysis and interpretation; HS: supervision and

critical review of the manuscript.

Acknowledgment

The authors are thankful for the kind cooperation of the Chattagram Civil surgeon’s office,

Chokoria Upazilla Health Complex, and Chattagram General Hospital.

Declaration

All the authors approved to publish this work.

Funding

Not applicable.



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TABLES:

Table 1: Baseline characteristics of the patients.

Parameters Number

Number of Patients 320

Male 208 (65%)

Female 112 (35%)

Age (mean ± SD) 35.81±11.07

Age of Male patients (mean ± SD) 34.15±11.07

Age of Female patients (mean ± SD) 38.89 ± 12.19

Asymptomatic 58 (18.12%)

symptomatic 262 (81.88%)

Hospitalized 129 (40.31%)

Home isolation 191 (59.69%)

Duration of symptoms (days ± SD) 5.66 ± 3.60

Male, Duration of symptoms (days ± SD) 5.72 ± 3.50

Female, Duration of symptoms (days ± SD) 5.56 ± 4.0

Body temperature <1000 F 68 (30.90%)

Body temperature >1000 F 152 (69.09%)

Comorbid condition (n) 152 (47.50%)



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Table 2: Symptomatic presentation according to gender variation. The total number of patients

n=320.

Symptoms No. of

Patients

Male Female % Against male

Symptomatic

Patients, n=164

% Against female

Symptomatic

Patients, n=98

Fever 220 157 (71.36%) 63 (28.64%) 95.73% 64.29%

Weakness 134 98 (73.13%) 36 (26.87%) 59.76% 36.73%

Cough 126 92 (73.01%) 34 (26.87%) 56.10% 34.69%

Anorexia 117 81 ((69.23%) 36 (30.77%) 49.39% 36.73%

Mayalgia 112 87 (77.68%) 25 (22.32%) 53.05% 25.51%

Diarrhoea 98 61 (62.24%) 37 (37.76%) 37.20% 37.76%

Nausea 94 69 (73.40%) 25 (26.60%) 42.07% 25.51%

Chest

tightness

93 52 (55.91%) 41 (44.08%) 31.71% 41.84%

Sleep

disturbance

83 51 (61.44%) 32 (38.55%) 31.10% 32.65%

Headache 75 58 (77.33%) 17 (22.67%) 35.37% 17.35%

Sore throat 63 30 (47.61%) 33 (52.38%) 18.29% 33.67%

Breathing

difficulty

61 43 (70.49%) 18 (29.51%) 26.22% 18.37%

Rhinorrhea 53 30 (56.60%) 23 (43.31%) 18.29% 23.47%

Abdominal

crump/pain

53 27 (50.94%) 28 (52.83%) 16.46% 28.57%

Skin rash 47 18 (38.30%) 29 (61.70%) 10.98% 29.59%

Vomiting 29 22 (75.86%) 7 (24.13%) 13.41% 7.14%

Vertigo 11 3 (27.27%) 8 (72.73%) 1.83% 8.16%

Restless 82(25.63

%)

57 (69.51%) 25 (30.49%) 34.76% 25.51%



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Table 3: Comorbid conditions n=152

Name of disease Number of patients and %

T2DM 47 (30.92%)

HTN 64 (42%)

IHD 17 (11.2%)

Sinusitis 13 (8.55%)

Bronchial Asthma 23 (15.13%)

HBV (+) Ve 10 (6.58%)

H/O Pulmonary TB 7 (4.61%)

T2DM and HTN 42 (13.13%)

T2DM, HTN, and IHD 9 (2.81%)

Others (Skin allergy,

Migraine, Thyroid disease,

etc)

20 (13.16%)



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Table 4: Hematological findings.

Parameters Number of

Patients

Mean±SD Range Reference value

Age (In years) 50 42.8 ± 8.268 31- 59

Hemoglobin (gm/dL) 46 13.42 ± 1.324 11.5 – 16.3 F: 12-16; M: 14-

18

ESR (mm in 1st hour) 46 29.52 ± 18.46 4 – 46 F: 0-15; M: 0-10

WBC 46 6851 ± 2721 4300 – 16000 4000 – 11000

RBC (Million/CC) 46 4.94 ± 0.65 3.75 – 5.94 4.2 – 6.2

Platelet 46 229804 ±

68932

160000- 421000 150000 – 450000

Neutrophil (%) 46 65.43 ± 12.11 48 – 75 40 - 75%

Lymphocyte (%) 46 28.72 ± 11.97 20 – 45 20 – 45%

Monocyte (%) 46 3.89 ± 2.42 2 – 10 02 – 10%

Eosinophil (%) 46 1.96 ± 1.26 0 – 5 01 – 06%

Basophil (%) 46 0.065 ± 0.24 0 – 1 0-1%

CRP (mg/dl) 43 16.65 ± 18.81 0.95 – 60.2 <3

SGPT (Unit/L) 25 72.04 ± 49.56 22 – 181 Male: 16-63

FM: 14-59

Serum Ferritin

(ng/ml)

26 659.9 ± 488.9 169 – 1550 Male: 13-370

FM: 9-253

Prothrombin Time

(Seconds)

10 14.35 ± 0.95 13.6 – 15.7 13

D-Dimer (µgm/ml) 12 0.25 ± 0.28 0.025 – 0.68 <0.5

Serum Creatinine

(mg/dl)

12 1.08 ± 0.17 0.89 – 1.3 Male: 0.7-1.3

FM: 0.5-1.2



19

FIGURES:

Figure 1: A- Number of total patients and gender difference of infected in number and

percentage. B- Variation in age according to gender and age group. C- Duration of presenting

symptoms in general and according to gender. D- Percentage of hospitalized and home isolation-

treatment according to gender. E- Number of the COVID-19 patients according to age group.

Note: 31 to 40 years is the highest and 10 to 20 years is the lowest affected group. F- Duration

and grade of fever (<1000F and >1000F) as presenting symptom of COVID-19 disease.



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Figure 2: Presenting symptoms in percentage (A) and number (B) against the total of COVID-19

patients included in this study. C- Symptomatic and asymptomatic cases of COVID-19 patients

in number. D- Presentation of the number of patients with or without fever against the total

number of COVID-19 patients included in this study. E- Analysis of cough (Dry and with

sputum) as a presenting symptom. F- Age variation according to the gender in the case of

Hospitalized and home isolated patients.



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Figure 3: Presenting symptoms (in percentage) of male and female symptomatic patients (A &

B). C- Differential count of WBC cells, presented as mean ± SD. D & E- Laboratory findings of

the hematological changes (in percentage). F- Differential expression of WBC among the

patients. G- Significant changes in decrease hemoglobin level and increased SGPT level in Male

and Female patients.



analysis of the primary presenting symptoms and

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